10 years in Facial Feminization

The best way to begin this Workshop on Facial Feminization Surgery (FFS) is to pose the following question: is the face important when it comes to recognizing a person’s gender? Indeed, modifying facial gender in the... [ view full abstract ]

The best way to begin this Workshop on Facial Feminization Surgery (FFS) is to pose the following question: is the face important when it comes to recognizing a person’s gender? Indeed, modifying facial gender in the transition protocol is without doubt as important as hormone therapy and genital reconstruction. Feminizing what are visually identified as masculine facial traits raises the self-esteem and confidence of patients, leading to greater acceptance in their personal and family circles, better adaptation in the workplace, and a dramatic decline in social rejection which, unfortunately, a large number of transgender patients continue to experience to this day.

Our goal with this Workshop is to present the latest advancements in FFS techniques and our clinical analysis after operating 650 transgender male-to-female patients: a 10-year experience. Any patient undergoing FFS must have... [ view full abstract ]

Our goal with this Workshop is to present the latest advancements in FFS techniques and our clinical analysis after operating 650 transgender male-to-female patients: a 10-year experience. Any patient undergoing FFS must have clear, detailed information about the techniques, how they are carried out, as well as the associated preoperative and postoperative experience and all of the potential risks and complications.

The purpose of FFS is to offer solutions principally for transgender women who wish to feminize facial features, possibly due to issues related to body dysmorphic disorder or gender dysphoria. Throughout our experience with 650 FFS patients to date, we have continually implemented improvements at all levels of our protocols in the FFS process. Our intention to innovate comes from the belief that this healthcare regime indeed needs to be considered as a sub-process within the longer transitional process, which deserves further attention in order to standardize and therefore improve overall service.

Four talks comprise this Workshop (for clarity issues each one appears in each of the boxes below).

Talk 1Tittle: Introduction to Facial Feminization SurgerySummary: Facial Feminization Surgery encompasses a group of surgical procedures designed to soften and modify facial features perceived as masculine or non-harmonic, and... [ view full abstract ]

Talk 1
Tittle: Introduction to Facial Feminization Surgery

Summary:
Facial Feminization Surgery encompasses a group of surgical procedures designed to soften and modify facial features perceived as masculine or non-harmonic, and which, therefore, are decisive in the visual identification of facial gender. These features are defined by different craniofacial skeletal structures. In general, the three basic pillars of craniofacial gender are the frontonasal-orbital complex, the nose and the jaw and chin complex. However, other structural elements, including the cheeks or the trachea, are also important when addressing a patient’s feminization needs. One of the most important preliminary steps in FFS is a meticulous evaluation and diagnosis of the patient. Each patient has a unique facial structure with specific features responsible for the male identification of the face, so it is important to adapt surgical options to a patient's individual needs rather than taking a standardized approach. This diagnosis includes an accurate clinical evaluation, imaging tests, an evaluation of patient requests and adjusting expectations. Additionally, the systematic collection of photographs is extremely important throughout the entire feminization process.

Talk 2Tittle: FFS in the upper third of the faceSummary: Given that: (1) a forehead reconstruction is indicated for a high percentage of patients who require hairline correction; and (2) the reconstruction involve obtaining,... [ view full abstract ]

Talk 2
Tittle: FFS in the upper third of the face

Summary:
Given that: (1) a forehead reconstruction is indicated for a high percentage of patients who require hairline correction; and (2) the reconstruction involve obtaining, during the approach, a strip with a large number of follicular units (FU) that can be harvested, our team decided to develop a new surgical sequence to treat the whole upper third during the same surgery: Forehead Reconstruction and Simultaneous Hair Transplant (FR and SHT). Between October 2012 and April 2016 we performed 85 FR and SHT. To access the forehead a modified temporoparietoccipital coronal approach was used in 11% of the cases, while a modified temporoparietal coronal approach was used in the 89% remaining patients. No complications were reported. The average number of FU per strip was 1489 ± 302. A classification method for hairlines in MtF transgender patients is proposed based on the observation of 492 patients.

Talk 3Tittle: FFS in the middle third of the faceSummary: Rhinoplasty surgical techniques which provide a correct support and stability in the mid- to long-term are essential for obtaining a predictable result. In the context... [ view full abstract ]

Talk 3
Tittle: FFS in the middle third of the face

Summary:
Rhinoplasty surgical techniques which provide a correct support and stability in the mid- to long-term are essential for obtaining a predictable result. In the context of FFS, a rhinoplasty has three objectives: (1) to feminize the nose; (2) to harmonize the nose in relation to the other modified structures (mainly the forehead and maxillomandibular complex); and (3) to achieve an aesthetic result beyond gender differences. The main goal of rhinoplasty in FFS is to change masculine nasal features to feminine ones by performing dorsal reduction, tip refinement and narrowing the nasal bones, most often using an external approach and cartilaginous grafts to provide good tip support and long-term stability. Lip lift and frontonasal recontouring can be technically complementary to rhinoplasties associated with facial feminization. Overall patient satisfaction with the operation was scored using the Nose Feminization Scale. The majority of the patients perceived their nose as feminine after the surgery and the degree of satisfaction after the rhinoplasty was 4 (much better) out of 5.

Talk 4Tittle: FFS in the lower third of the faceSummary:1) Jaw and chin. The possible goals of this treatment include: modifying the width and height of the jaw, softening the jawline and modifying the size, shape and position... [ view full abstract ]

Talk 4
Tittle: FFS in the lower third of the face

Summary:
1) Jaw and chin. The possible goals of this treatment include: modifying the width and height of the jaw, softening the jawline and modifying the size, shape and position of the chin. Likewise, feminization techniques for the jaw and chin do not affect or modify the patient’s bite. Access to the jaw and chin should always be via intraoral approaches to prevent visible external scars. On many occasions, it is necessary to treat the jaw and chin as a whole. In this case, we recommend connecting the incisions through a subperiosteal tunnel, which creates an excellent working area, avoids an overly large incision (mandibular degloving) and helps to protect the mental nerves by not exposing them. Surgical techniques are based in bone sculpture, namely burring, standard osteotomies (bone cutting), osteotomies with piezosurgery (ultrasonic cutting) and endoscopic control.
2) Adam's apple. To approach the Adam's apple, we recommend making an incision distant from the cartilage itself, preferably in the region of the cervicomental fold. According to the characteristics of the cartilage (hardness, position), the reduction can be performed by burring or using a scalpel.